and Review. Vol. XXXIII. TORONTO, JANUARY, 1908. Original Communications. SYRINGOMYELIA.* F. ARNOLD CLARKSON, M.B. No. 1 Syringomyelia (σvpıy—a hollow pipe), or gliosis spinalis, is a peculiar condition of cavity formation in the spinal cord, first described as a pathological entity in 1824. It was not, however, till 1887, after the publishing of monographs by Schultze and Kahler, that we were able to diagnose the disease during life. Since then, although it is a comparatively rare condition, a good many cases have been observed, Schlesinger, in the year 1895, giving references to 526. The following case is interesting because it presents some features of the disease in its early stages. Albert L., age 23, born in England, the only child of healthy parents, who are both living. In childhood he had tuberculous adenitis on the left side of the neck, and one of the glands can still be felt slightly enlarged and hardened. About the same time, also, he had "trouble with his eyes," for which he was treated by Dr. Nettleship. This was probably a phlyctenule. Six years ago he was unconscious for some minutes after a fall from a bicycle, his left ear being partly torn from the head. Three years ago, while working in a deep excavation, a lump of clay fell about 18 feet and struck him between the shoulders. He was off work for three weeks after this accident, not confined at all to bed, and feeling, as he expressed it, "not quite up to the mark," but he noticed afterwards that his right hand, Read before the Academy of Medicine, Toronto, November 12th, 1907. when cold, became numb. both warmth and sensation. Brisk rubbing, however, restored He recalls now, that twelve months ago he remarked to his mother that the water in the wash-basin was cold only to his left hand. Present Illness. Since he first landed in Canada last April, the fingers of his right hand have gradually become stiff and the hand itself has withered. Four months ago, while working at his trade of a bricklayer, he cut his hand with a trowel, but felt no pain and did not know for some time that the skin had been broken and that the wound was bleeding. This injury took a long time to heal and the scar is still present. A few days ago he had a blister on his thumb from using an axe. This was ruptured in the course of his work, and yet he felt no pain. He has noticed that the goose-flesh comes more quickly on his right forearm than on other parts of his body. He perspires, too, more freely on the right hand. Because he is no longer a capable workman he has had to relinquish his employment, and he now presents himself for medical treatment for the atrophy of the hand muscles. Physical Examination. The patient has a splendid muscular development, having been for some years a trained gymnast. The optic discs are healthy. The ocular muscles and the pupillary reflexes are normal. Hearing, vision, taste, and smell seem to be unimpaired. The skin of the right hand is purple and cold to the touch, although the patient says it feels perfectly comfortable. The right forearm measures 25 cm.; the left 27 cm. There is no tremor of either hand. The thenar and hypothenar eminences have almost disappeared, and the metacarpal bones are prominent from the atrophy of the lumbrical and interosseous muscles, while the condition of main en griffe is quite evident. The patient says that he noticed the wasting first in the small muscles of the thumb. The movements of the fingers are much impaired. He cannot approximate the fingers and thumb, nor can he abduct the fingers. The grasp of the right hand is very weak, and its movements clumsy, so that he has difficulty in buttoning his clothes. The nails on his hand are slightly ridged. The muscles of the arms and forearms are firm and apparently healthy. There is no spinal curvature. The muscles of the right thigh are less firm than those of the left. His station is good and he has no ataxia. The Reflexes. Are absent in the right arm and only slightly present in the left. The patellar reflex on the right side is in creased, but there is no ankle clonus. nor Mendel reflex can be obtained. Neither the Babinsky Sensation. All portions of the body examined showed an acute sense of touch, and a perfect muscular sense. Heat and cold, however, are not felt at all, or very imperfectly over the right hand and forearm to the elbow, and over the anterior and posterior surfaces of left hand and arm half-way to the elbow. In all other parts of the body the thermal sense is very accurate. Over the right hand, back and front, to the wrist, there is a complete absence of pain. The boundaries of these zones of analgesia and thermo-anesthesia vary slightly at different examinations. There is no involvement of the sphincters and the course of the disease so far has been painless. The Etiology is absolutely unknown. In many cases it is probably due to an anomalous embryonic condition, which, sooner or later, gives rise to cavities in the cord, uninfluenced by external circumstances. Blows upon the back have been noted many times, and this case adds another to the list. Buzzard has seen syringomyelia develop within a short time after an injury to the spine. Cases have been observed following infectious diseases and childbirth. Syphilis, alcohol and heredity, three etiological factors so very prominent in neurology, play no part whatever in this disease. The age of onset is most often between 11 and 30, and males are greatly in the majority. Pathology. This disease is characterized by the formation of cavities within the spinal cord, sometimes involving the central canal, but more frequently embracing the posterior commissure, and extending laterally in an irregular way to the posterior horns and posterior columns. The anterior cornua may be involved, but the lateral tracts almost always escape. The form and size of the individual cavities are as irregular as the mode of extension. Very often a portion of the interior of the cavity is lined with cylindrical epithelium, the remains. of the central canal, and a zone of thick neuroglial tissue forms a wall, which is usually ruptured at the autopsy, allowing the turbid fluid contents to escape. The lower cervical and upper dorsal regions are always first involved, extension taking place later either upwards or downwards. Microscopically, we find an increase of neuroglia around the cavity, the cells nearest the lumen often being vacuolated, and showing other signs of breaking down. Few capillaries are found in the wall itself, but in the surrounding tissue the vessels are abundant, more tortuous and of greater |